Provider Demographics
NPI:1790849180
Name:LULL, CHARLES R (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:LULL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:155 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-3690
Mailing Address - Country:US
Mailing Address - Phone:504-889-0347
Mailing Address - Fax:504-779-9741
Practice Address - Street 1:935 WAYNE RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-1937
Practice Address - Country:US
Practice Address - Phone:504-889-0347
Practice Address - Fax:504-779-9741
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD00000077402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN132751OtherFEDERAL BLACK LUNG
TN3029154OtherBLUE CROSS
TN3093872Medicaid
TN1640237OtherUNITED HEALTHCARE
TN300067251OtherRAILROAD MEDICARE
TN5001678OtherMEMPHIS MANAGED CARE TLC
TN000000118528OtherUNISON HEALTH PLAN
TN300067251OtherRAILROAD MEDICARE
TN3093872Medicaid